Provider Demographics
NPI:1710540323
Name:IKEGBUNAM, OBIANAJU NICOLE (MD)
Entity type:Individual
Prefix:DR
First Name:OBIANAJU
Middle Name:NICOLE
Last Name:IKEGBUNAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:IKEGBUNAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:8722 CROWN JEWEL DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77469-9405
Mailing Address - Country:US
Mailing Address - Phone:832-860-8430
Mailing Address - Fax:
Practice Address - Street 1:1575 I 30
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6905
Practice Address - Country:US
Practice Address - Phone:469-800-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXU0361207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program